Disclosure: No conflicts of interest to declare 9/21/2018

Transcription

1 SBIRT + Management: Managing Substance Use Disorders in Health Care Settings 42 nd Annual Educational Conference International Nurses Society on (IntNSA) October 3-6, 2018 Katherine Fornili, DNP, MPH, RN, CARN, FIAAN Assistant Professor, Univ. of Maryland School of Nursing President, International Nurses Society on IntNSA( ) Disclosure: No conflicts of interest to declare 1

2 TERMINOLOGY: SBIRT: Screening, Brief and Referral to : Traditional SBIRT PLUS Management Background-Screening & Brief 1990: Improved alcohol screening recommended (IOM, Broadening the Base of for Alcohol Problems, 1990) 2003-present: Federally-funded SBIRT projects 2007: 5 th decade of evidence, yet under-implemented in primary care (Saitz, 2007) : SBIRT-related measures endorsed National Institute on Drug Abuse (Tai, Wu & Clark, 2012) The Joint Commission (2014) The National Quality Forum (2014) 2018: 6 th decade of evidence, still under-utilized 2014: Those two studies in JAMA (Saitzet al., and Roy-Byrne et al.) Claimed that brief interventions were not effective for decreasing drug use among primary care patients identified through screening; But was it really fair to claim that widespread adoption of screening and brief intervention for drug use was not warranted?? 2

3 2017: Rethinking Brief s (McCambridge & Saitz) Stronger scrutiny of the evidence: Discussion content and counseling micro-skills associated with improved outcomes Alcohol screening: Not isolated from other risky behaviors and mental health questions More clarity: Remaining questions about unmet needs of people with alcohol problems Brief interventions as guiding principle: Reduction of substance use and consequences (not defined by time or # of sessions) Unanswered Questions: Absence of Evidence is Not Evidence of Absence Alcohol Misuse Alcohol Dependence Drug Use Drug Dependence SCREENING BRIEF INTERVENTION REFERRAL TREATMENT SBIRT has many moving parts, and its measurement is tricky (Lindsay, 2014) Analysis of Theoretical Framework Purpose for Examining Middle-Range Theories To conceptualize clinical problems and outcomes To delineate effective interventions and methods of outcome measurement (Donaldson, 1995) Utilized Smith and Liehr sevaluation Framework for Middle Range Theory Substantive foundations Structural integrity Functional adequacy (Smith & Liehr, in Gaubard & Rosen, 2008) 3

4 Two SBIRT-related Middle Range Theories Wagner s Chronic Care Model (CCM) Featured prominently in early SBIRT literature (Bodenheimer, Wagner & Grumbach, 2002; Coleman, Austin, Branch & Wagner, 2009) White s Management (RM) Model Component of the Ecology of Addiction Model; Adapted from Brofenbrenner s Ecologic Framework Model (William White, 2008) Wagner s Chronic Care Model (CCM) CCM is associated with changes in: Provider expertise & skill; Patient education & support Team-based care delivery; and Better use of information systems CCM does not articulate how it can be used to improve substance use disorder outcomes Management (RM) Model Specifically addresses the needs of individuals with substance use disorders, their families and communities Outperforms the CCM in terms of describing, explaining and interpreting the phenomenon of interest (recovery) 4

5 (William White, 2008; adapted from Brofenbrenner s Ecologic Framework Model) Phenomenon of WORKING DEFINITION: (SAMHSA, 2011) A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential. CORE MEASURES: (SAMHSA, 2014) Health Overcoming or managing disease process; physical/emotional well-being; Home Stable and safe place to live Purpose Meaningful daily activities (job, school); and Community relationships and social networks that provide support, friendship, love and hope. Screening, Brief, and Referral to PLUS Management () Model for Managing Substance Use Disorders in Primary Care Settings Management (RM) Pre- Support and Support 5

6 4 Key Concepts of the Management Model Management (RM) Pre- Support and Support The Management Model Management (RM) Pre- Support Therapeutic Primary Care alliance Provider Responsibilities between the practitioner and the individual: Practitioner: Awareness of a window of opportunity to intervene Substance Individual: Use Awareness Disorder Services that the Continuum-of-Care healthcare provide is helpful and supportive and Support The Management Model Management (RM) Pre- Support Failure Primary to Care initiate Provider and Responsibilities stabilize recovery is often viewed SBIRT + as the failure (non-compliance) RM of the individual rather than flaws in the design or execution of the referral protocol (White, 2008) and Support 6

7 The Management Model Management (RM) Pre- Support Primary Child Care care Provider Responsibilities Transportation Housing Life skills training Employment readiness Legal consultation Wellness checks Self-management support and Support The Management Model Management (RM) Pre- Support Primary Shifting Care focus Provider from Responsibilities service environment to the client s SBIRT natural + RM environment; Substance Service Use commitment Disorder Services to Continuum-of-Care extended posttreatment monitoring and Support and support Management and the Substance Use Disorders (SUDs) Continuum-of-Care Management (RM) Pre- Support and Support 7

8 The Substance Use Disorder (SUDs) Continuum-of-Care Management (RM) Pre- Support and Support The Substance Use Disorder (SUDs) Continuum-of-Care Management (RM) Pre- Support and Support The Substance Use Disorder (SUDs) Continuum-of-Care Management (RM) Pre- Support and Support 8

9 The Substance Use Disorder (SUDs) Continuum-of-Care Management (RM) Pre- Support Continued contact is the Primary responsibility Care Provider of Responsibilities the primary care provider and other service staff rather Substance than Use the Disorder Services Continuum-of-Care patient. and Support Looking at SBIRT Through a Traditional Lens: SCREENING Management (RM) Pre- Support SBIRT SCREEN NEGATIVE PREVENTION MESSAGES: Congratulations for Low Risk and Support Looking at SBIRT Through a Traditional Lens: BRIEF INTERVENTION Management (RM) Pre- Support SBIRT SCREEN POSITIVE (Mild) BRIEF INTERVENTION MESSAGES: Recommended limits; Reduce risks & consequences and Support 9

10 Looking at SBIRT Through a Traditional Lens: REFERRAL TO TREATMENT Management (RM) Pre- Support SBIRT SCREEN POSITIVE (Severe) REFERRAL MESSAGES: Serious need for specialist, encouragement & support and Support REFERRAL TO TREATMENT Least-studied of the three components (Dr. Dawn Lindsay, IRETA, 2015) Successful referrals depend on: Type of Referral Access to Follow-up Provided Self-help and/or Peer/ Support How Success is Measured RM Theory and Healthcare Provider Responsibilities Traditional SBIRT is a Support JOB HALF-DONE Management (RM) Concepts Pre- Traditional SBIRT and Support 10

11 BOTH HALVES OF THE PUZZLE Management (RM) Pre- Support and Support What if behavioral health problems and specialty referrals were addressed like other types of health care problems? CHRONIC CARE SUBSTANCE USE DISORDERS ACUTE CARE Conclusions: The SBIRT+RM Model Provides insight into why SBIRT alone may not be effective for more serious substance use disorders (drug use, alcohol/drug dependence) Articulates how the proposed Model can enhance outcomes of substance use disorder interventions delivered within primary care settings Will help individuals in recovery lead safe, healthy, meaningful lives in the community, surrounded by people who love them and encourage them to succeed 11

12 For More Information Katherine Fornili, DNP, MPH, RN, CARN, FIAAN Assistant Professor University of Maryland School of Nursing Dept. of Family & Community Health Academic/Clinical Partnership: Upper Chesapeake & Harford Memorial President-Elect ( ) President ( ) International Nurses Society on Office: "Knowing is not enough, we must apply. Willing is not enough, we must do." Goethe 12